RICHMOND, Va.—I’m an ER doctor in central Virginia, and just a few weeks ago, I would have told you that after 15 years’ experience, I’m ready for anything, including the coronavirus.
“Looking forward to going in and kicking butt, like our kids on game day, but with a lot more personal protective equipment,” I recently texted one of my sports-mom friends.
Now, however, I’m not feeling so confident. Being an ER doctor as our country braces for the impact of COVID-19 feels like standing on the shore and watching a tsunami approach.
I work nights in a small community emergency department, and as the only physician in the entire hospital, it’s up to me to handle whatever comes through the door. I’m scared. And the reason isn’t just this disease, it’s the equipment we need—and don’t have—to fight this fight.
Last week, just days after they announced the first two COVID-19 cases in my home state of Virginia, I asked where we keep our stocks of N95 masks. These aren’t the more common soft, surgical masks; N95 masks are harder, tighter around your nose and mouth, and constructed to filter out 95 percent of airborne particles. I have a small supply of N95 masks in my ER, but if we were hit with a sudden wave of suspected COVID-19 patients, I wanted to know where to get more. The answer was that they are locked in a manager’s office and can only be accessed during nightshift by calling hospital security. I’m not surprised they’re under lock and key, given concerns about theft and hoarding. Already, there has been at least one case in Richmond of someone bursting into an ER waiting room, grabbing a box of masks, and fleeing.
The dwindling supplies of personal protective equipment in front-line hospitals like mine isn’t scaring just me—it’s scaring my physician friends around the country, with shortages of N95 masks, gowns, goggles and gloves being reported in states from New York to Washington. This is the equipment that gets wrapped together as “PPE,” an acronym unfamiliar to most people but a standard—and critical—term for any front-line health care worker. When a patient comes in with an infectious disease, PPE is what lets you keep being a doctor instead of becoming the next patient, and maybe the next statistic.
This week, we received the same warning that emergency department teams everywhere are hearing: Once this disease arrives in force, our PPE supply will not last.
To preserve them, we are being asked to wear masks only when treating suspected COVID patients, and those masks should be the less-safe surgical masks—they'll block droplets, but not invisible, aerosolized virus. In other words, surgical masks will work if someone coughs or sneezes in the room, but not if I’m doing a procedure like intubating, in which I’m close enough to inhale aerosolized particles.
Right now, we’re being told we should use N95s only for procedures on known COVID patients who put us at the absolute highest risk of exposure. When we do use an N95, we’re supposed to store it to be re-used indefinitely until it’s either soiled or gets fluid on it from a positive COVID-19 patient. In the worst-case scenario, the CDC is telling us we can put a bandana over our face.
I’ve seen the pictures of Chinese health care workers in protective ensembles that are far more elaborate than anything I have available. I’ve read the New England Journal of Medicine study that detected coronavirus in aerosols for up to three hours, and I know I really need to be wearing an N95 mask, not just a surgical mask, to protect me from aerosolized spread. I know two emergency room doctors like me have already fallen ill and are in critical condition — one in his 70s in New Jersey and one in his 40s — roughly my age — in Washington state. Both are in the ICU fighting for their lives.
I can’t help but feel that we should have been better prepared. Even during the Ebola scare—for a disease that barely appeared on American shores—we used head-to-toe impermeable garb that left not one single inch of skin exposed. Despite the fact that a U.S. citizen was more likely to die from a vending machine falling on them than from Ebola, we did serious drills on how to don and doff these spaceman-like suits. I remember having to get checked off on my donning and doffing proficiency before I was allowed to be responsible for any potential Ebola patients. Now, if we still have these wonder suits in our hospitals, they are not being brought out. Why are we comparatively so much less frightened about the coronavirus, which is more ubiquitous and has already killed significantly greater numbers of people?
ER docs are fighting a war, but we are not young, impressionable soldiers who will blindly stumble into battle unprepared. The more dire the circumstance, the more critically we question possible paths forward. The current path we are on is not sitting well with me, or many of my colleagues.
First of all, we question how safe it is to protect ourselves only around patients with symptoms. We know asymptomatic people are spreading the virus — as early as three days before showing symptoms. For now, in Virginia, my patients with head injuries and heart attacks are much less likely to have asymptomatic COVID-19 than patients in New York or California, but that might not be true for long. Soon the virus will be widespread enough for us to have a high index of suspicion for COVID in anyone, whether they have respiratory symptoms or not. We already might be at that point; we just don’t know it because of the paucity of testing.
A colleague recently saw a patient triaged as “headache.” Only after he got close enough to put a stethoscope on her chest did she divulge that it was sinus pressure accompanied by fevers, cough and exposure to a family member who recently returned from Europe. We need enough PPE to wear a mask with every patient regardless of complaint.
Secondly, real life in the ER is nowhere near as neat and clear as the algorithms our public health officials are creating. While I’m trying to risk-stratify patients to know what level of protection I’m supposed to use according to the latest algorithm, I’m simultaneously navigating inefficient computer systems, fielding questions from three different people, trying to get to the multitude of patients waiting for me, and watching EMS crews bring even more patients through the door. As my colleague learned with his headache patient, patients don’t always give the full story when they’re triaged. Also, the virus won’t always wait for the highest risk interactions like intubating and suctioning to take the opportunity to spread. We shouldn’t wait until we intubate or suction to wear N95s. Furthermore, the COVID test is not always completely reliable. Just like the flu test, there are going to be false negatives.
Thirdly, board certified emergency physicians are too precious a resource—just 39,000 of us for the entire country—to be gambling with their health. In small hospitals like mine, physician groups are small and staffing is slim with limited backup. Trust me, with our expertise in making fast decisions and rapidly directing flow, you want veteran ER doctors on the front lines protecting you, not quarantined, ill or dead. Without enough PPE, it’s a matter of when, not if we go down. Physicians from other specialties will take our place, but they will not have the same skills. The ophthalmologists, orthopedists, or nephrologists who will replace us in the ER will do their best, but with no disrespect to our friendly eye, bone and kidney specialists, are they really the doctors you want to see when you arrive in the ER with a suspected coronavirus infection?
The demoralizing reality I face is that more PPE might not be coming. So last week I went to my local hardware store and bought myself a face shield. I’m posting on social media, along with other doctors and nurses on the front lines, using the hashtag #GetMePPE. It’s crazy to be a physician shopping in a hardware store for medical equipment.
Meanwhile, I’m losing sleep over the predicament of having no good course of action. Do I use masks with every patient to protect myself from asymptomatic spread and risk running out of masks entirely? When the PPE runs out, do I keep going in, like a firefighter charging into a burning building in a Speedo and flip-flops? The deaths of Italian doctors Roberto Stella and Marcello Natali, who valiantly kept working without PPE, are a terrifying warning.
Will I come to a point where I have to make a decision about saving my family or saving my patients? I worry about my two teenage sons and my parents in their 70s. My family didn’t sign up to take this risk. In an attempt to protect them, I’ve set up a decontamination zone in my laundry room—when I come home after my shift, I go straight to the laundry room, strip and leave all work paraphernalia there before setting foot in the rest of the house and hugging my kids. Last night I cried as I made the decision that, if it comes to a shelter-in-place situation, my sons will stay with other family members, not with me. There is nothing harder for a mother.
The public support for us as we deal with these challenges is humbling. Suddenly ER doctors are heroes. I have never in my career been thanked and praised so much for doing my job. However, if my colleagues and I are going to have a fighting chance to protect our citizens, we need more than words of encouragement.
Last week, President Donald Trump called for construction companies to donate masks. New legislation signed Wednesday will let U.S. manufacturers sell N95 masks made for industrial uses to hospitals without fear of liability. On Thursday, the president invoked the Defense Production Act, to give the federal government authority to harness industrial production, but has not yet forced any companies to produce equipment. In Virginia, distilleries have started making hand sanitizer; dentists and schools are providing their own medical supplies to health care facilities. Virginia Gov. Ralph Northam activated our National Guard to be on call to help transport supplies that health care facilities need. This isn’t enough. This past weekend, Virginia’s Health and Human Resources Secretary Daniel Carey warned us that “this will not be solved without a national solution.”
Without more serious action to provide the armor we need on your front line—not just now, but for months, maybe years, as long as this virus is sweeping through an unimmunized population—this disease will be picking off health care workers one by one.
Please don’t let me be one of them.